Priority 2 – Traumatic Cardiac Arrest

Traumatic Cardiac Arrest (TCA)

Establishing the cause of cardiac arrest may not be straightforward. A primary medical arrest can occur before a patient suffers a secondary traumatic insult. Primary medical cardiac arrests resulting in falls from height or while driving are examples that can typically result in rescuers suspecting cardiac arrest of traumatic origin.

Where trauma is considered to be the primary cause of the arrest, consider early enhanced care support and follow the traumatic cardiac arrest algorithm pictured here (click to zoom in).

HOT Approach

In the pre-hospital setting, advanced life support and exclusion of reversible causes using the 4Hs and 4Ts or the HOT approach should take priority. The commonest causes of traumatic cardiac arrest are hypovolaemia, oxygenation (hypoxia) and tension pneumothorax, which form the mnemonic ‘HOT’ – a helpful short checklist of reversible causes for the management of these patients.

Rapid treatment of reversible causes should take priority over chest compressions and ALS drug administration. However, high-quality chest compressions are important and may generate some forward flow, even in cases of severe hypovolaemia or cardiac tamponade; it is therefore important to continue chest compressions as soon as sufficient personnel are available to allocate someone to this task.

Blunt Trauma

Effective airway management using a stepwise approach is essential to maintain oxygenation of the severely compromised trauma patient.

Hypovolaemia due to blood loss that is sufficient in volume to cause cardiac arrest is difficult to treat. Gain large bore IV access. Although IV normal saline may restore blood volume (often requiring 2–3 litres), excessive crystalloid causes coagulopathy, acidosis and hypothermia, which in itself worsens outcome. Request enhanced care, particularly if it enables blood and blood products to be brought to scene without delay. Once ROSC is achieved, only give IV fluids to achieve a systolic BP no higher than 80 mmHg.

Consider whether the patient can be conveyed for early blood or blood product intervention, or whether this can be brought to the scene or to a rendezvous point in a timely manner by enhanced care assets.

In blunt trauma cases, where ALS (including attempts to address reversible causes) is being delivered, clinical judgement may be applied as to whether enhanced care assets may be accessed, or the patient can be conveyed to an MTC (or TU if necessary) in a timely manner.

Penetrating Trauma

In penetrating traumatic cardiac arrest, patients should be transferred rapidly to hospital because surgical intervention is often needed to treat the cause of the arrest. A rapid transport approach is appropriate to the nearest MTU (or TU if necessary), but crew safety should be a consideration where there are prolonged journey times in a moving vehicle.

Enhanced care assets should be requested early for attendance at the scene (but do not delay departure from scene while waiting for these assets) and/or during conveyance.

Rapidly address immediate issues: